What is the treatment for metopic craniosynostosis?

Treatment for Metopic Craniosynostosis

Surgical correction via fronto-orbital advancement and remodeling is the definitive treatment for metopic craniosynostosis, ideally performed before 12 months of age to prevent increased intracranial pressure and optimize aesthetic outcomes. 1, 2, 3

Surgical Approach and Timing

• Primary surgery should be performed at approximately 11-12 months of age to achieve optimal correction while the skull is still malleable enough for remodeling 2, 3
• The standard procedure is fronto-orbital advancement with cranial remodeling to correct the characteristic trigonocephaly (triangular forehead) and hypotelorism (narrowed intercanthal distance) 2, 4, 3
• Aggressive anterolateral expansion of the supraorbital bar using interpositional bone grafts with resorbable fixation provides superior long-term aesthetic outcomes compared to simple reshaping 5
• The surgical goal should be overcorrection rather than exact correction to prevent long-term relapse and temporal hollowing 5

Surgical Technique Evolution

Modern technique emphasizes:

• Maximal expansion of the supraorbital bar via interpositional bone grafting 5
• Strategic bone grafting with resorbable fixation rather than metallic hardware to stabilize the construct 5
• Lateral reinforcement of the expanded bar to reduce reoperation rates (statistically significant reduction, p=0.026) 5

Expected Outcomes and Complications

Major complications occur in 2-4% of cases, with minor complications in approximately 7% 6, 3

Common postoperative findings include:

• Temporal hollowing develops in 36-57% of patients, particularly with longer follow-up (>5 years shows 2.9-fold increased risk) 6
• Lateral orbital retrusion occurs more frequently with extended follow-up (4.9-fold increased risk with >5 years follow-up, p=0.001) 6
• Secondary raised intracranial pressure requiring reoperation occurs in 2.9-9% of cases, with syndromic patients at significantly higher risk 4, 3

Critical Follow-Up Requirements

Long-term multidisciplinary follow-up is mandatory given the risk of late complications 4, 3

• Annual neurological assessment is recommended for all patients with craniosynostosis, though further investigations are not needed in asymptomatic patients 1
• Fundoscopic examination to evaluate for papilledema indicating increased intracranial pressure is crucial at each visit 1
• Ophthalmologic evaluation should be performed regularly, as vision defects occur in approximately 50% of cases 2
• Neurological assessment is essential, as neurological abnormalities occur in approximately 40% of cases despite corrective surgery 2

Secondary Procedures

Secondary surgery rates range from 3-15% depending on indication 4, 6, 3

Indications for secondary intervention:

• Secondary raised intracranial pressure (2.9-9% of cases) requiring calvarial expansion 4, 3
• Aesthetic contouring procedures for residual forehead irregularities or temporal hollowing (approximately 15% of cases) 3
• Hardware removal when metallic fixation was used 3

Prognostic Factors

Preoperative intercanthal distance <20mm predicts higher incidence of postoperative frontal irregularities (p=0.045) 5

Patients with preoperative frontal irregularities have higher rates of postoperative deformities (p=0.026) 5

Syndromic patients have significantly higher rates of secondary raised intracranial pressure requiring additional surgery 4

Common Pitfalls

• Undercorrection is a common finding that leads to poor long-term aesthetic outcomes and higher revision rates 5, 6
• Aesthetic outcomes worsen significantly over time, with patients followed >5 years showing 4-fold increased odds of Whitaker class III/IV classification (p=0.006) 6
• Simple suturectomy or ridge burring should be reserved only for the mildest cases, as more aggressive remodeling provides superior outcomes 2